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psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
December 14, 2022 - For this reason, researchers purport that the Safety-II view helps us understand the value of variability
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psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
July 31, 2023 - Regina Hoffman: That is our primary reason for existence—to support interorganizational learning.
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - For this reason, researchers purport that the Safety-II view helps us understand the value of variability
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psnet.ahrq.gov/perspective/building-capacity-patient-safety
July 31, 2023 - Regina Hoffman: That is our primary reason for existence—to support interorganizational learning.
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - Ultimately, the big reason I think there are lots of challenges in quality and safety in the ambulatory
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - participants should be able to:
Understand the history, epidemiology, cause of latex allergy and the reason
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psnet.ahrq.gov/periodic-issue/periodic-issue-285
April 28, 2021 - March 31, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/periodic-issue/periodic-issue-298
June 30, 2021 - June 30, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
-
psnet.ahrq.gov/periodic-issue/periodic-issue-331
March 31, 2022 - March 2, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
-
psnet.ahrq.gov/periodic-issue/periodic-issue-343
May 16, 2022 - May 25, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - In Conversation With… Lucian Leape, MD
April 1, 2015
In Conversation With… Lucian Leape, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-lucian-leape-md
Editor's note: Dr. Lucian Leape is Adjunct Professor of Health Policy at the Harvard School of Public
Health, Chairman of the Lucian …
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - Monitoring Fetal Health
January 1, 2015
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/monitoring-fetal-health
Case Objectives
Define fetal heart rate monitoring.
Describe the current state of evidence regarding fetal heart rate monitoring.
List the known …
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and
Directo…
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School.
Her la…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
-
psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also
p…
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status
December 18, 2019
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
Disclosure of Relevant Financial Relationships: As a p…
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psnet.ahrq.gov/web-mm/translating-normal-abnormal
October 02, 2019 - SPOTLIGHT CASE
Translating From Normal to Abnormal
Citation Text:
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibT…
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
The Case
A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…